addressing sdh: a three pronged approach...egic reso development and programming 1,000 900 800 700...

Montefiore ■■■■■■■ HUDSON VALLEY / ~ . COLLABORATIVE

Montefiore DOING MORE~

Montefiore Health System’s Innovations

Addressing SDH:

A Three Pronged Approach

Amanda Parsons, MD, MBA

Vice President, Office of Community & Population Health

Damara Gutnick, MD

Medical Director, Montefiore Hudson Valley Collaborative

~ Montefiore ■■■■■■■ HUDSON VALLEY / ~ . COLLABORATIVE


Montefiore’s Three Pronged Approach

1

Implement & Incentivize SDH

Screening

2

Enable CBO Linkages

3

Training &

ROI Tools

~ Montefiore ■■■■■■■ HUDSON VALLEY ~~ COLLABORATIVE

WHAT MATTERS TO YOU?

~ .r. :\,

FINANOAL

8 TRANSPORTATION -w

HOUSING

HOSPITAL

CARE MANAGEMENT e PHARMACY

BEHAVIORAL HEALTH o e e> e

FOOD/NUTRmON SOCIAL SERVICES

Montefiore DOING MORESM

Prong 1: SDH Screening

• Montefiore Implemented SDH

Screening at over 20 primary

care sites

– Adapted Healthleads Tool

– >14,000 patients screened

between April-Aug 2018

• Screen Positive (20%)

• Want Assistance (26%)

• MHVC Incentivized SDH

screening in DSRIP network

contracts

– >50 partner organizations

– Hospital EDs, PCP, BH, SU, CBOs

• What Matters to You? − Patients prioritize SDH needs − Get to the heart of the matter up

front, saves time − Ask, Listen, Do What Matters!

~ Mont{ ....... HUDSON VALLt:Y ~~ COLLABORATIVE

Data shown are limited to Census Tracts w,th more than 20 SOH/StreSSO< screeners completed .

Food security problems (%) (:] MMC Hospitals

W NYCHA Developments

892

687656

575

494 476 462417

211

SDH Risk Factors

SDH Screenings: Patient Reported Risk FactorsApril August 2018

N=14,272

Yes

SDH Screening:

Patients Reporting

Housing Quality

Money for Food

Housing Situation

Healthcare Transportati

Healthcare Cost

Getting Along

Utilities Shutoff

Child or Adult Care

Need Legal Help

Threats and Safety

Actionable Data to Inform Strat

urce

894

Nu

mb

er

of

Pat

ien

t R

esp

on

ses

--

Risk

% Reporting

Risk

6.2%

6.2%

4.8%

on 4.5%

4.0%

3.4%

3.3%

3.2%

2.9%

1.4%

egic

Reso Development and Programming

1,000

900

800

700

600

500

400

300

200

100

0


Connecting Healthcare to Self Car~

NIWPow e::, ll!.1. of si,1tl!s. ;iod P!"CW~ms. n~2r ~ th-Yi .lrl!: m:xthod 10 j'OOI' SPfilnC. hi!! .and ~ oc,,:d';.. Th MG J:'oltci: .lfld f)fO@JillfflS [iffl

t"~ you U~ hlt.tthy. Im'.,! lni:!'"P~fl!1M lly, :artd (l'l.lrt.l ll~"r:;il


Prong 2:

Facilitating & Enabling CBO Linkages

• PPS Consortium

– Aligned with multiple PPSs networks

around common solution

• Now Pow

– CBO referral management &

tracking platform

– Curated & maintained CBO

database

• ~ 211 priority CBOs live

– Automated resource suggestions

based on patient needs & location

– EHR integration

• supports patient “nudges” & closed loop referral tracking

– ~3500 resource lists shared to date

• Adapted by: - NYP, Maimonides, H+H, Mt.

Sinai, Montefiore, Northwell • Under consideration by others



Prong 2: Facilitating & Enabling CBO Linkages

• “This requires our employees to learn another system and check

another system when they are trying to see clients.

• We want to select something that we can use for ourselves for

internal referrals…

• …and connects to our multiple database systems.

• we are going to have a capacity issue because programs are

literally pieced together with several small grants

• More people coming to our programs is going to strain the

program resources”.

- Concerned Bronx CBO

Dear Montefiore Health System,

I understand we serve as one of your biggest resources in terms of

services for your patients. Our mission is to help the residents of

the Bronx.

HOWEVER…



Prong 3: CBOs Return on Investment Training, Coaching & Tools

CBO Challenge: • Technology is NOT enough

- Lack Infrastructure to collect & report data

- Ability to demonstrate ROI

ROI Calculator Leverage real cost inputs to help

CBOs quantify their impact on reducing overall costs (PPR,PPV).

Business Case Coaching New Perspective:

From Public Good to MCO

VBP Training Modules “Moving from Government Work to Retail”

“Bringing Your Innovation to Market.”

~ Montefiore ■■■■■■■ HUDSON VALLEY ~ COLLABORATIVE

Innovation Cost Ptr~onntl

fr ing:,e

OTPS

Travtl

Contractors

Phone/Utllltl es

Other

Otner

Other

Admin

Total Innovation Cost

Innovation Revenue

Medica id

Mi!dicare

Commetcla I1

l •Timt GrMt R!Ct ivtd IStart•UPI

G'u~ ran eed Grant Fu ndin11 bvYear

Total Innovation Revenue

s s s s s s s s s s s

s s

_S_

s Current/Starting Cost Benchmark Values (Baseline)

Emergency Department Visit Medical or BH

Inpatient Day Medical or BH

High l.ltillzer - l Year Medlca'I (PRIOR TO I NOVA TIO

Hi h Utilizer· 1 Year BH !PRIOR TO I NOVA TIO )

Innovation Period

Projected Impact

Emergency Department Vis it

Inpatient Day

Hi~h UUlizer - l Year Medica l

Hll!)h UUUzer-1 YearBH

1

Innovat ion Cost $110,000

ED Unit,s Avoided 200

Inpat ient 50

High Cost Med 0

High Cost BH 0

n1, 1 100,000 $

30,000 s S,000 s

$

s $

$

$

s <l0.000 s

175,000 s Year 1

6S,000.00 s s s s s

65.000 s

$ $

1

Yeor2

Year2

200

50

Cost Avoidance Value

$150,000

$ 100,000

$ 50,000

$0

$ 0

I 103,000

30,900

S,150

41,200

180, 250


PUS

OUTPUT

Prong 3: ROI Calculator Demo

1

Costs associated with supplying the service

Expected Revenue (Medicare, Medicaid, Commercial)

Projected Impact (How many PPV’s or PPR’s will the

innovation prevent?)

Benchmark Costs (ED Visit, Hospital Day)

2

3

4

INPUTS

OUTPUT

Return on Investment

~ Montefiore ■■■■■■■ HUDSON VALLEY / ~ . COLLABORATIVE


Montefiore’s Three Pronged Approach

Now Pow • Curated CBO

database

• Adapt standard SDH Screening Tool • Integrate SDH screening into EHR

workflow • Incentivize SDH Screening • WMTY Campaign to prioritize SDH

needs

1

Implement & Incentivize SDH

Screening

2

Enable CBO 3

Linkages Training &

ROI Tools • VBP Training Modules

• CBO referral management & tracking

• Business Case Coaching for Innovation Pilot Projects

• ROI Calculator

Tha k You & Ac nowledgeme ts

MHS


Partners HVC

Einstein SO

HVC In ovation

Fun Partners W 0

part· cipated, pi o ed &

earned with us!

M ontefiore DOING MORE'"

Thank You & Acknowledgements

“The opposite of poverty isn’t wealth.

The opposite of poverty is justice.”

MHS

Nicolette Guillou Kevin Fiori Jacob Schutt Sybil Hodgson Alissa Mallow Renee Whiskey Rahil Briggs Neil Wigod Eva Franqui Colin Rehm Urvashi Patel

Partners

Mt. Sinai NYP Maimonides Northwell St. Barnabas H+H Bronx Works NOW POW GNYHA NYS Medcaid

MHVC

Allison McGuire Marlene Ripa Joan Chaya Christina Hamilton Rachel Evans Kristin Woodlock

Einstein SOM

Bruce Rapkin Rosy Chhabra Kathleen McAuliff

MHVC Innovation

Fund Partners who

participated, piloted &

learned with us!

Bryan Stevenson

Appendix

Montefiore DOING MORE'M

IT TOOK MHS MANY MEETINGS, SEVERAL PILOTS AND ALMOST A YEAR TO REACH CONSENSUS ON A SINGLE SCREENING TOOL (LAUNCHED IN APRIL 2018)

Social Determinants of Health Screening Tool rolled out at Montefiore Medical Group sites

1. Are you worried that in the next 2 months, you may not have a safe of stable place to live? (eviction, being kicked out, homelessness)

2. Are you worried that the place you are living now is making you sick? (has mold, bugs/rodents, water leaks, not enough heat)

3. In the past 12 months, has the electric, gas, oil or water company threatened to shut off services to your home?

4. In the past 12 months, did you worry that your food could run out before you got money to buy more?

5. In the last 12 months, has lack of transportation kept you from medical appointments or getting your medications?

6. In the last 12 months, did you have to skip buying medications or going to doctor’s appointments to save money?

7. Do you need help getting child care or care for an elderly or sick adult? 8. Do you need legal help? (child/family services, immigration, housing discrimination, domestic

issues, etc…)? 9. Are you finding it hard to get along with a partner, spouse, or family members? 10. Does anyone in your life hurt you, threaten you, frighten you or make you feel unsafe?

MHVC encouraged participating providers to adopt a screening tool (TBD Damara language)

on of onprofits

. .... Jun 2017

Speaker: Kristin Woodlock RN, MPA - CEO, Woodlock & Associates

addressing sdh: a three pronged approach...egic reso development and programming 1,000 900 800 700...

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